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DAA 2104

Health Care on a Ship

Amy Lehman, AB '96, MBA '05, MD '05, is on a mission to bring better access to health care to more than three million people living along a remote, landlocked lake in central Africa - by building a floating clinic. She is founder and president of Lake Tanganyika Floating Health Clinic.

By Rebecca Rolfes and Judith Crown

A typhoon during a 2007 trip to Lake Tanganyika in central Africa changed more than Amy Lehman's travel course.

The storm that imperiled the boat Lehman, AB '96, MBA '05, MD '05, was on also wiped out the airstrip where she was supposed to be picked up. To get back to home base, she and her school-age son traveled overland in a car for more than 10 hours through countryside where there were no paved roads.

"As I'm bouncing around in this car, I'm wondering, 'How do you bring services to people in a part of the world that has no infrastructure?'" Lehman, recalled during an interview from her home office on Chicago's near west side.

Back in Chicago where she was a resident in general surgery at the University of Chicago Medical Center covering the cardiac surgery intensive-care unit, Lehman did a back-of-the-envelope calculation. It cost about $2 million that week to keep her mostly elderly, terminally ill patients alive. How many people in central Africa, especially children and young mothers, could she help for that amount?

Soon after, she decided to make her life's work bringing health care and a better life to as many of the 3.5 million people as she could reach who live along Lake Tanganyika in the nations of Burundi, the Democratic Republic of the Congo (DRC), Tanzania, and Zambia. On subsequent visits, it became evident to Lehman that the conventional approach of building more hospitals in population centers wasn't a sound option in a region where there are such poor roads and where residents use the lake as their highway. The way to bring health care to local residents would be by boat.

Lehman resolved to do what many involved in the problem of global poverty would call impractical, if not impossible. She would go to this place - landlocked poverty stricken, plagued by wars - and build a floating clinic. Not a little boat with a resident doctor plying the waters like some latter-day Dr. Livingstone, but a fully equipped hospital ship with two onboard operating rooms, an ICU, and a small inpatient ward; ship-to-shore loading equipment for land-based patient registration and treatment areas; and outboard motorboats for use as ambulances.

For that she would need an organization with staff on the ground, the buy in of four governments, a credible reputation among donors and the local population, a supply chain, and $30 million. It would prove to be what she calls, a "huge, insane, massive project."

CASTAWAY TO CAPTAIN

Lehman grew up in the Chicago north-shore suburb of Evanston. She attended boarding school on the East Coast where she met students from Africa and became interested in postcolonial politics and literature. After receiving her bachelor's degree from the University of Chicago, Lehman spent a stint teaching introductory biology at the school before entering the joint degree program at Booth and the University of Chicago medical school.

"I was interested in the idea of decision making under stress," she recalled. "Surgeons do that all the time. You help families make the right decisions for their loved ones and patients make the right decisions for themselves." At Booth, she appreciated the way behavioral economists such as Richard H. Thaler, Charles R. Walgreen Distinguished Service Professor of Behavioral Science and Economics, probed questions of human behavior - behaviors that she observed as a medical student, such as why people continue to smoke knowing the detrimental effects.

It was during her residency that she visited Tanzania and Lake Tanganyika for the first time - a trip she had wanted to take since high school - and found the area "incredibly interesting, compelling, and beautiful." Once she made the decision to dedicate her life to Lake Tanganyika, she began making frequent trips to the region and established the nonprofit Lake Tanganyika Floating Health Clinic (LTFHC). She visited small businesses along the 1,140-mile coast of the lake to learn about the methods of supply distribution, the local norms for service, and the differing customs of the four nations. She also got to know the health-care facilities and professionals struggling to serve local communities. She formed two boards, one in the US and one Africa-based and gained access to local, regional, and national government officials and decision makers, ultimately gaining their support.

Lehman quickly realized that building a floating clinic was not only about medicine per se; it was a complex supply-chain and logistics project because the region is so remote and underdeveloped. The DRC has less than 30 miles of paved road per one million people and many of the impoverished lakeside communities have no access to roads. What infrastructure exists has been frequently disrupted or destroyed by repeated wars.

It's no surprise then, that health care is bare bones. Local clinics are often mud huts. When there is an operating room, doctors carry water and wash in a bucket. "There are women who need to be referred to a place where they can get a safe C-section and where the baby and the mother can be healthy," Lehman said. "That doesn't exist."

Mwele Malecela, chief research scientist and director general at the National Institute for Medical Research, Tanzania, and a member of both LTFHC boards, said that Lehman's vision started with the "why" - determining the real need rather than a perceived one. "The dream is built on a solid sense of realism, of understanding the dynamics of the region and the fact that it will not happen overnight," Malecela said.

Lehman's project differs from the work of nongovernmental agencies such as Doctors Without Borders, which deploys doctors and nurses for disaster relief. "A lot of international development work does not get beyond the last mile," said Michael Madnick, former deputy director for external relations in global health policy and advocacy at the Bill & Melinda Gates Foundation and an advisor to the project. "This program is designed to help people who live beyond that last mile."

Madnick noted that Lehman has worked to gain the cooperation of the governments around the lake and the trust of the people who live there. "It's a significant task to put that all together and she has done it. It's a pretty heavy lift but she's beginning to have some traction," he said.

Lehman said her Booth education - and its emphasis on fundamentals and first principles - has helped her frame her approach to the complexities of her ambitious goal. For example, while working on long-term plans for a hospital ship, she has developed short-term goals such as building a radio network that will enable rural health centers to communicate with each other, as well as distant regional hospitals.

"You're breaking things down and putting them back together again in a new, exciting, or innovative way that excites and compels other people because you've done so by building a case, presenting evidence, and being rigorous about it," she said. That way, she added, people are more apt to listen to new ideas and say, "OK, I'm willing to follow along with you. I'm willing to get shipwrecked on the shores of Lake Tanganyika and see what happens next."

YOU'RE A SMART PERSON

Lehman's ambitious plan leads her to spend much of her time fundraising. She makes frequent speeches and appeals to small groups. It can be daunting. "People want to deploy philanthropic dollars in very safe, 'low-hanging fruit' kinds of ways," she said. Moreover, Lehman explained, you can't go to a lending institution and say, "I'd like to build communications infrastructure in the 'Triangle of Death,'" the area of the DRC plagued by rebel groups, massacres, and massive numbers of refugees. She asks donors to view their philanthropy as "risk capital."

Nevertheless, in the past five years, she has raised $3.5 million, much of it from small family foundations and wealthy individuals. That is enough to hire a staff of 15: some in Chicago and Washington, DC; local field staff based at LTFHC's compound in Kigoma, Tanzania, one of the largest communities on the lakeshore, as well as in Moba and Kinshasa, DRC. In addition, the organization has completed several outreach projects.

Her business education helped. She shows potential donors a comprehensive business plan with a full set of financial projections. "Having a business background is critical when working with ministries in developing nations to get things done," said Caren Yanis, president of Crown Family Philanthropies, which funded Lehman's initiative last year to expand LTFHC's high-frequency radio network and introduce the region's first electronic medical record in southern Tanzania, impacting a population of 78,000. "We look for data collection, analysis, and improvement against targets. It is essential to moving policy forward and tracking change. In addition to helping individuals in the area, the metrics [Lehman] provides on the population in the Lake Tanganyika basin have the potential to improve regional health policies and can be used by other organizations in identifying where the need lies."

Lehman's Booth credentials and the school's network have helped her line up resources. "When I talk to potential supporters, they're often stunned," she said. "You're a doctor and you went to Booth? OK, you're a smart person."

A talk Lehman gave to students at Booth in 2010 was covered in school publications, and subsequently picked up by an alumnus who forwarded the story to a friend, saying, "Get a load of this girl, you'll like her."

The friend was James "Ace" Lyons Jr., a retired US Navy admiral and former commander of the US Pacific Fleet. Impressed by what he read, Lyons called Lehman, offered to help, and connected her to a Naval architecture and engineering firm, Alion Science and Technology Corp., in McLean, Virginia. Lehman has lined up other contractors, too: shipbuilders JGH Marine of Denmark and Songoro Marine Transport Ltd. of Tanzania, along with Mobile Medical International Corp., a Vermont company that specializes in building out nonstandard medical spaces. All have agreed to work at a discounted rate, she said.

Lehman sees potential for an alliance with the energy companies interested in developing oil and gas reserves identified in the region. They understand the dangers - the need to counter local insurgents and build community support. They also are comfortable taking a long-term view. "You make this massive upfront capital investment, but it's years before you will turn a profit," Lehman said.

The floating clinic is similar. "We need to create an upward trajectory of results and value over time," she said. Her team plans to publish a white paper this year, "From Curse to Cure," on the impact of energy exploration and production in the region.

SKIN IN THE GAME

Those who have met Lehman or heard her speak learn that she has a detailed map of Lake Tanganyika tattooed down her back. In the summer of 2009, Lehman was in a shipwreck with a LTFHC intern, Brian Bartlett, '09, now a consultant on the ship-building team, and other colleagues. "We were near to shore, but the boat was flooded and we were stuck on this beach for 36 hours," she recalled. "As I was sitting there, I thought, 'I'm going to tattoo a map of Lake Tanganyika on my back.' So I came back and did it.

"It's a powerful marketing tool, she asserted. She owns a closet full of backless shirts and dresses, and when people at conferences ask where she works, she swirls around. "They gasp, but they don't forget," she said. "There's a reason I got an 'A' in marketing at Booth. So I've differentiated myself, if nothing else. Who else has skin in the game like this?"

No one can doubt her commitment when you consider it takes three days to reach Lake Tanganyika from most US cities. While her compound in Kigoma has beds and indoor plumbing, once she's in the field, there is often no plumbing, running water, or electricity. "We're basically camping out, cooking on a propane stove or fire."

Lehman admits that her personality drives her to "go out and do the hardest thing." And her Booth education prepared her for dealing in a world of uncertainty. "Do I have a plan A though K? Yes. Would I prefer plan A, B, C, or even D to happen? Yes. But am I prepared to go all the way to plan K? Yes. I'm prepared to do whatever it takes being practical, pragmatic, flexible, and nimble."

In the past five years, LTFHC has distributed thousands of bed nets in Tanzania and the DRC to help prevent malaria, installed communications equipment at health-care facilities in both countries, and provided surgical procedures to dozens of women, incorporating local health-care worker training as a core component of these initiatives.

It may be a while until a hospital boat is operational on Lake Tanganyika, but "the fact is," said Malecela, the medical researcher, "if anyone can do it, Amy Lehman can." ■

Photo by Chris Strong

Amy Lehman explains her plan to serve the impoverished communities on Lake Tanganyika by building a hospital ship. She also discusses how her Booth education with its emphasis on fundamentals and first principles helped her frame her approach to the complexities of her ambitious goal. View the video »

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GETTING THERE

Getting to Lake Tanganyika from most major US cities takes the better part of three days. A trip from Chicago might involve a flight to Amsterdam, a connection to Dar es Salaam, Tanzania, and then a flight on a local carrier to Kigoma, Tanzania, on the eastern shore of the lake. Flying from other US cities, passengers might connect through Zurich, Munich, or Frankfurt. There also is an unreliable rail line from Dar es Salaam to Kigoma. Flying to the DRC, on the western shore of the lake, is more involved. It includes a flight to the capital city of Kinshasa via Brussels (many air routes reflect historic colonial relationships) and a UN humanitarian flight to Kalemie via other cities. Reaching the lake by flying to the southern DRC city of Lubumbashi from Johannesburg, South Africa, (also a hub for the region) and then driving is another option. The 100-year old passenger-and-cargo ferry MV Liemba connects Kigoma with Mpulungu, Zambia, on the southern tip of the lake and with the ports in between. ■

BUILDING A BOAT

June 2010The team begins distribution of 15,000 mosquito nets in the DRC.

Fall 2010Dear Mothers, a short film commissioned by the Sundance Institute's Documentary Film Program, is included in a communications platform for the Bill & Melinda Gates Foundation.

October 2011A mix of foundation, corporate, and private funding enables LTFHC to provide fistula surgery to 44 women, train staff, and procure supplies to three hospitals/health centers in Tanzania and the DRC.

February 2012A US and Tanzanian ship-building team of experts meet for the first time at the Kigoma, Tanzania, shipyard.

March 2012An HP Global Social Innovation grant enables installation of communications equipment at nine health-care facilities in Moba, DRC, so they can communicate with each other and the regional hospital.

November 2012LTFHC opens first office on Lake Tanganyika in Kigoma.

February 2013The LTFHC begins research in DRC to create a database cataloging medicines used by traditional healers and the sources of commonly used medicinal plants.

October 2013A grant from the Crown Family enables expansion of communications capability to clinics in Tanzania and introduces the region's first electronic medical record.